Residential care facilities (RCFs) are an important part of the long-term services and supports system. In 2010, 31,100 RCFs served 733,300 residents of all ages and with a wide variety of physical and mental impairments (Caffrey et al., 2012; Park-Lee et al., 2011). By comparison, in the same year, the United States had 15,682 nursing homes serving 1,396,448 residents (Kaiser Family Foundation, 2012).

States vary in the degree to which they have developed an array of home and community-based services (HCBS) that includes a substantial role for RCFs (Stone & Reinhard, 2007). In some states, such as Oregon and Washington State, RCFs play an important role in the HCBS system, specifically to reduce nursing home use and to increase service options for individuals who want to live in the community (Kane & Cutler, 2008; Wiener & Lutsky, 2001). Thus, RCFs are a critical component of efforts to alter the balance between institutional and HCBS spending.

At its core, the key policy questions are where RCFs fit in the range of long-term services and supports and what role they should play. Some view RCFs as community-based residential settings for individuals who cannot be safely served at home for any number of reasons but do not yet need to be cared for in a nursing home. Others view RCFs as settings that can serve a more severely disabled population, substituting for nursing home care in some instances. This latter view is reflected in the provision of residential care services as part of Medicaid HCBS waivers (O'Keeffe et al., 2010).

An assessment of the current and future role of RCFs is complicated by the multitude of ways in which states regulate facilities (Mollica, Sims-Kastelein, & O'Keefe, 2007; Polzer, 2011; Wiener, Lux, Johnson, & Greene, 2010). Unlike nursing homes, there are no minimum federal standards as to what services RCFs must provide. Little is known about the health, functional, and cognitive characteristics of the people who live in the facilities; what services are offered by facilities and used by residents; and what levels and types of staffing are provided. Importantly, it is unknown whether the services offered by facilities and used by RCF residents and the staffing provided by these facilities match the health, functional, and cognitive needs of the residents. In other words, do residents with greater health, functional, and cognitive needs live in facilities that provide more services and higher levels of staffing? Until recently, little current, nationally representative data has been available to inform policy makers on these issues (Hawes, Phillips, & Rose, 2000; Stone & Reinhard, 2007). This report analyzes these issues using the most current and comprehensive data available, the 2010 National Survey of Residential Care Facilities (NSRCF).

Although most research on RCF residents is quite old, some studies found that RCF residents are less impaired than nursing home residents, and others found that RCF residents have substantial impairment (Zimmerman et al., 2003), in some cases similar to that found in nursing home residents. A more impaired RCF population may result from both allowing residents to "age in place" and admitting more impaired residents (Stone & Reinhard, 2007). A study of primarily elderly residents of RCFs with 11 or more beds in the late 1990s also found that RCF residents were generally healthier and had less impairment than nursing home residents. This study indicated that, on average, 23.6 percent of residents of assisted living facilities, which are a subset of RCFs, were considered by administrators to be "heavy care" (i.e., they received assistance with three or more activities of daily living [ADLs]), and 34 percent had moderate to severe cognitive impairment (Hawes, Phillips, Rose, Holan, & Sherman, 2003). In a more recent study using the 2010 NSRCF, 38 percent of RCF residents received assistance with three or more ADLs (Caffrey et al., 2012).

RCFs are major providers of services to people with Alzheimer's disease and related dementias. Analysis of data from the 2010 NSRCF found that 42 percent of RCF residents had Alzheimer's disease (Caffrey et al., 2012). The findings of several studies indicate that about half of all elderly RCF residents had Alzheimer's disease, another condition that causes dementia, or cognitive impairment (Hawes et al., 2003; Rosenblatt et al., 2004; Sloane, Zimmerman, & Ory, 2001). One study suggested cognitive impairment rates in RCFs ranging from 45 percent to 63 percent (Morgan, Gruber-Baldini, & Magaziner, 2001). A study of 192 residents in 22 RCFs in Maryland found that the prevalence of dementia ranged from 63 percent to 81 percent, with facilities of 16 or fewer beds having a higher percentage of residents with dementia (Leroi et al., 2007).

Other studies compared RCF residents with residents in nursing facilities. One study comparing Medicare beneficiaries living in either nursing homes or RCFs found that RCF residents are generally less impaired than nursing home residents and have a lower prevalence of chronic diseases (Spillman, Liu, & McGilliard, 2002). A set of studies of 347 residents with dementia in 45 RCFs and nursing homes in four states found that: (1) 56 percent of RCF residents had behavioral symptoms related to dementia, compared with 66 percent of nursing home residents (Boustani et al., 2005); and (2) 24 percent of RCF residents had depression, compared with 27 percent of nursing home residents (Gruber-Baldini et al., 2005). A study using the same data found that 49 percent of RCF residents had moderate to high mobility impairments, compared with 53 percent of nursing home residents (Williams et al., 2005). In these studies of four states, although the results show that RCF residents had lower rates of these conditions than nursing home residents, the differences between the two populations were not large.

States differ in what services they require to be licensed. Beyond those minimum requirements, facilities vary in what services they provide and in what services residents actually receive. Hawes and colleagues (2000) defined a set of "basic" services that RCFs offer that included two meals a day, housekeeping, 24-hour staff oversight, and assistance with either medications and at least one ADL or assistance with two or more ADLs. The study classified all RCFs as high, low, or minimal-service facilities. The minimal-service facilities, which did not provide any basic services, composed 5 percent of all facilities nationally; low-service facilities, which provided some but not all basic services, composed 65 percent of all facilities; and high-service facilities, which provided all basic services, composed 31 percent of all facilities. The survey data at the time showed that 99 percent of all facilities offered housekeeping services and at least two meals a day; 92 percent provided medication reminders; 97 percent provided assistance with bathing; 94 percent provided assistance with dressing; and 71 percent of all facilities had any full or part-time licensed nurse on staff (registered nurse [RN] or licensed practical nurse [LPN]), with 79.5 percent of facilities providing any care or monitoring by RNs or LPNs (Hawes et al., 2003).

Analyses of the 2010 NSRCF found that--although nearly all facilities provide personal care, basic health monitoring, incontinence care, social and recreational activities within the facility, special diets, and personal laundry services--provision of skilled nursing care, occupational and physical therapy, and social service counseling is less common (Park-Lee et al., 2011). It is important to note that offering ADL assistance or health-related services like medication management was one of the criteria for inclusion in the survey.

In the late 1990s, the National Survey of Assisted Living found that 75 percent of individuals leaving RCFs over a 7-month period did so because they needed more care (Phillips et al., 2003), indicating that the level of care provided was not sufficient to meet their needs. Some of this finding could be explained by state licensing rules that prohibit the provision of nursing care in RCFs. Although this study reported many positive aspects about RCFs, it also found that needs for assistance were unmet by 26 percent of residents for using the toilet, 12 percent for locomotion, and 12 percent for dressing.

Staffing is a key variable in determining whether a facility has enough resources to meet the needs of its residents. In the late 1990s, the National Survey of Assisted Living found that 29 percent of facilities had no licensed nurse on staff and 65 percent did not have an RN on staff at least 40 hours a week (Hawes et al., 2003). A 2002 study of six states that use Medicaid to pay for services in RCFs found that virtually all stakeholders had concerns about insufficient numbers of staff, untrained staff, and the potential negative impact of these staffing patterns on the quality of care (O'Keeffe, O'Keeffe, & Bernard, 2003). Other researchers have argued that because RCFs often lack professional staff, they may not adequately address the functional and health care needs of persons with dementia (Pruchno & Rose, 2000).Few states establish staffing ratios for RCFs, preferring to give facilities the flexibility to vary staffing patterns based on residents' care needs. No consensus exists about the appropriate type and level of staffing needed in RCFs, particularly nurse staffing. A major problem in reaching such a consensus is that the type and amount of care provided varies significantly across settings, as do the needs of the residents (O'Keeffe & Wiener, 2005).

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